ACUTE GASTROENTERITIS

IN CHILDREN
 Epidemiology of acute diarrhea:
developed versus developing
countries.
Per year Estimated Hospitalizatio Deaths
episodes of ns
acute
diarrhea

United States 375 million 900 000 total 6000 total

1.4 episodes
per person per
year 200 000 300 children
> 1.5 million children
child outpatient
visits

Worldwide 1.5 billion 1.52 million

episodes children < 5 y
In developing
countries,
children < 3 y
 NON-INFECTIOUS CAUSES
ERRORS IN FEEDING ( WRONG
FORMULA, WRONG DILUTION)
FOOD INTOLERANCE
INFLAMMATION OF THE GUT
CELIAC DISEASE
GUT SURGERY
MUCOVISCIDOSIS
INFECTIONS OUTSIDE DIGESTIVE
 Bacterial gastroenteritis
Bloody diarrhea
Child appears systemically ill : sepsis
Greater degree of dehydration
Abdominal pain
Raised inflammatory markers
Stool culture will show leucocytes
> 5 /hpf

Extra abdominal organ involvement :

Bacteremia - osteomyelitis
- meningitis
- endocarditis
 Common pathogens
Campylobacter
Salmonella
Shigella
Yersinia
Pathogenic E.coli

Cause 10 15 % of diarrheal illness

Under developed nations consider
vibrio species
 Diarrheagenic Escherichia coli. All forms cause
disease in children in the developing world, but
enterohemorrhagic E. coli (EHEC, including E. coli
O157:H7) causes disease more commonly in the
developed countries.
Enterotoxigenic E. coli (ETEC) travelers
diarrhea, diarrhea in infants and children in
developing countries.
Enteropathogenic E. coli (EPEC) children < 2 years;
chronic diarrhea in children; rarely causes disease in
adults.
Enteroinvasive E. coli (EIEC) bloody mucoid
diarrhea; fever is common.
Enterohemorrhagic E. coli (EHEC) bloody diarrhea;
severe hemorrhagic colitis and the hemolytic uremic
syndrome in 68%; cattle are the predominant reservoir.
Enteroaggregative E. coli (EAggEC) watery diarrhea
in young children; persistent diarrhea in children and
adults with human immunodeficiency virus (HIV).
 E.Coli O157H7
Epidemic / sporadic outbreaks

Contaminated food, partially cooked beef

Verotoxin producing EHEC

Affects 3 5yr olds

Prodromal gastroenteritis followed by

> acute renal insufficiency

> hemolytic anemia
> thrombocytopenia
 Campylobacter is prevalent in adults
and is one of the most frequently
isolated bacteria from the feces of
infants and children in developing
countries.
Asymptomatic infection is very
common in developing countries and is
associated with the presence of cattle
close to dwellings.
Infection is associated with watery
diarrhea and on occasion dysentery
(acute bloody diarrhea).
Peak isolation rates are found in
children 2 years of age and younger.
 GuillainBarr syndrome is a
rare complication.
Poultry is an important source
of Campylobacter infections in
developed countries.
The presence of an animal in
the cooking area is a risk factor
in developing countries.
 Shigella species.
There are 160 million infections annually in
developing countries, primarily in children.
It is more common in toddlers and older
children than in infants.
S. sonnei mildest illness; seen most
commonly in developed countries.
S. flexneri dysenteric symptoms and
persistent illness; most common in
developing countries.
S. dysenteriae type 1 (Sd1) produces
Shiga toxin, as does EHEC. It has caused
devastating epidemics of bloody diarrhea
with case-fatality rates approaching 10% in
Asia, Africa, and Central America.
 Vibrio cholerae.
Many species of Vibrio cause diarrhea
in developing countries.
V. cholerae serogroups O1 and O139
cause rapid and severe depletion of
volume.
In the absence of prompt and
adequate rehydration, hypovolemic
shock and death can occur within 1218
h after the onset of the first symptom.
Stools are watery, colorless, and
flecked with mucus.
 Vomiting is common; fever is rare.
In children, hypoglycemia can lead
to convulsions and death.
There is a potential for epidemic
spread; any infection should be
reported promptly to the public
health authorities.
 Salmonella.
All serotypes (> 2000) are pathogenic
for humans.
Infants and the elderly appear to be
at the greatest risk.
Animals are the major reservoir for
Salmonellae.
There is an acute onset of nausea,
vomiting, and diarrhea that may be
watery or dysenteric.
 Fever develops in 70% of affected
children.
Bacteremia occurs in 15%, mostly in
infants.
Enteric fever Salmonella typhi or
paratyphi A, B, or C (typhoid fever).
Diarrhea (with or without blood)
develops, and fever lasting 3 weeks or
more.
 Rotavirus.
Leading cause of severe, dehydrating
gastroenteritis among children.
One-third of diarrhea hospitalizations and
500 000 deaths worldwide each year.
Nearly all children in both industrialized
and developing countries have been infected
with rotavirus by the time they are 35 years
of age. Neonatal infections are a common
occurrence, but are often asymptomatic.
The incidence of clinical illness peaks in
children between 4 and 23 months of age.
Rotavirus is associated with gastroenteritis
of above-average severity.
 Rotavirus
Faeco oral transmission
6 24 months of age
Sudden onset watery diarrhea and
vomiting with little abdominal pain
Self limiting in healthy individuals
1 6 day duration
Seasonal - temperate climates: winter
gastro
- tropical climates: summer peak
Treatment : symptomatic
 Adenovirus.
Adenovirus infections most commonly
cause illness of the respiratory system.
However, depending on the infecting
serotype and especially in children, they
may also cause gastroenteritis.

Parasitic agents
Giardia intestinalis, Cryptosporidium
parvum, Entamoeba histolytica, and
Cyclospora cayetanensis most commonly
cause acute diarrheal illness in children.
These agents account for a relatively small
proportion of cases of infectious diarrheal
illnesses among children in developing
countries.
 Clinical evaluation
The initial clinical evaluation of the
patient should focus on:
Assessing the severity of the illness
and the need for rehydration
Identifying likely causes on the
basis of the history and clinical
findings
ONSET
Approach to Peds Dehydration

1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of
rehydration fluids
 Degree of Dehydration

Mild dehydration (3-5%)

Moderate dehydration (6-9%)

Sever dehydration (10-15%)

The skin pinch is less useful in infants or children with marasmus or kwashiorkor,
or obese children
Parameters of dehydration
3-5% 6-9%
>10%

Mental status N ill , not toxic

lethargic

Respiratory Rate N tachypnoea acidotic

Capillary refill N <2s 2 4s > 4s

Blood pressure N N
hypotensive

Urine
Theoutput N to down
best 3 individual examination signs are: down minimal
Prolonged Cap refill time
Abnormal Skin turgor
Abnormal resp pattern
 Three major classes of dehydration
based on relative losses of Na and
Water

1)Isonatremic dehydration (80%)

2)Hypernatremic dehydration (15%)
3)Hyponatremic dehydration (5%)
 Dehydration
Volume depletion - contraction of total IV plasma pool
Dehydration loss of plasma-free water disproportionate
to loss of
sodium
Isonatremic volume depletion :
most common in dehydrated children --- VOLUME
DEPLETION
Na and H20 lost in proportionate quantities
Excessive extrinsic loss of fluids
Hyponatremic volume depletion
Volume depletion with hyponatremia
Plasma volume contraction with free water excess
e.g child with diarrhea given tap water to replenish losses
Hypernatremic volume depletion
Volume depletion + dehydration
Plasma volume contraction + free water loss
 Isonatremic dehydration
By far the most common
Equal losses of Na and Water
Na = 130-150
No significant change between fluid
compartments
No need to correct slowly
Hypernatremic Dehydration
Water loss > sodium loss
Na >150mmol/L
Water shifts from ICF ( intracelular
fluid) to ECF
Child appears relatively less ill
More intravascular volume
Less physical signs
Alternating between lethargy and
hyperirritability
Hypernatremic Dehydration
Physical findings
Dry doughy skin
Increased muscle tone
Correction
Correct Na slowly
If lowered to quickly causes
massive cerebral edema
intractable seizures
 Hyponatremic Dehydration
Sodium loss > Water loss
Na <130mmol/L
Water shifts from ECF to ICF
Child appears relatively more ill
Less intravascular volume
More clinical signs
Cerebral edema
Seizure and Coma with Na <120
 Hyponatremic Dehydration
Correction
Must again be performed slowly unless
actively seizing
Rapid correction of chronic hyponatremia
thought to contribute to.
Central Pontine Myelinolysis
Fluctuating LOC
Pseudobulbar palsy
Quadraparesis
 Electrolytes 1
Hypernatremia : Na > 145meq/L
Causes :
- Water loss > electrolyte loss e.g. diarrhea
- Pure water depletion
-Sodium excess improper mixing of formula
Plasma tonicity increases . Cellular dehydration
Complications cerebral hemorrhage, seizures,paralysis,
encephalopathy
Clinically : abdominal wall skin doughy
Hyponatremia Na < 135meq/L
Causes :
- supplementation of fluid losses with hypotonic fluids
- loss from GI tract
Plasma tonicity decreases .. Cellular oedema
Complications - cerebral oedema
Clinically : tenting of skin on abdominal wall
 Electrolytes 2
Potassium

Serum potassium may not reflect true potassium

Usually potassium depletion, initially not significant
Consider as part of replacement fluids when adequate
urine output obtained

Acidosis

Bicarbonate loss in stools

Decreased renal perfusion less acids excreted
Decreased tissue perfusion lactic acid production
 Laboratory

CBC
Inflamatory tests
Stool analysis of leucocytes
Stool cultures
Measurement of serum electrolytes is only required in
children with severe dehydration or with moderate
dehydration (hypernatremic dehydration requires specific
rehydration methods irritability and a doughy feel to
the skin are typical manifestations and should be sought
specifically)
Tests such as BUN and bicarbonate are only helpful when
results are markedly abnormal
A normal bicarbonate concentration reduces the
likelihood of dehydration
No lab test should be considered definitive for
dehydration
DIFFERENTIAL DG
 DIFFERENTIAL DG

Meningitis
Bacterial sepsis
Pneumonia
Otitis media
Urinary tract infection
 Prevention

Water, sanitation, and hygiene:

Safe water
Sanitation: houseflies can transfer bacterial pathogens
Hygiene: hand washing

Safe food:
Cooking eliminates most pathogens from foods
Exclusive breastfeeding for infants
Weaning foods are vehicles of enteric infection

Micronutrient supplementation: the effectiveness of this

depends on the childs overall immunologic and
nutritional state; further research is needed.
 Rotavirus: in 1998, a rotavirus vaccine was
licensed in the USA for routine
immunization of infants. In 1999,
production was stopped after the vaccine
was causally linked to intussusception in
infants.
Currently, two vaccines have been
approved: a live oral vaccine (RotaTeq)
made by Merck for use in children, and
GSKs Rotarix.
Principles of appropriate treatment
for children with diarrhea and
dehydration WGO Practice
Guidelines
 Oral rehydration solution (ORS)
mmol/L
Sodium
constituents
75
Chloride 65
Glucose, anhydrous 75
Potassium 20
Citrate 10
Total osmolarity 245

1.For all children with diarrhea: 20 mg zinc

for 14 days.
2.In children who are in hemodynamic shock
or with abdominal ileus, ORT may be
contraindicated. For children who are
unable to tolerate ORS via the oral route
(with persistent vomiting), nasogastric
feeding can be used to administer ORS.
 Oral rehydration solutions
(ORS)
Osmoles Glucose Na Cl HCO3 K
mOsm/L mmol/L mEq/L mEq/L mEq/L mEq/L

WHO
formulatio
n 330 110 90 80 30 20
Pedialyte 270 140 45 35 30 20

AJ 730 690 5 x x 32
Sports
drink 330 255 20 x 3 3
D5W /
0.45%
saline 454 300 77 77 0 0
 ORT
Oral rehydration therapy
Appropriate for mild to moderate dehydration
Safer
Less costly
Administered in various clinical settings
Fluid replacement should be over
3-4hrs
50ml/kg for mild dehydration
100ml/kg for moderate dehydration
10ml/kg for each episode of vomiting or
watery diarrhea
Minimal or no dehydration.
Mild to moderate
dehydration
 ORT
Contraindications to ORT
Severe dehydration (10%)
Ileus or intestinal obstruction
Unable to tolerate (Persistent vomiting)
Signs of shock
Decreased LOC (Level of consciousness) or
unconscious
Unclear diagnosis
Psychosocial situations
Severe dehydration.
 Resuscitation
Emergency resuscitation phase

Re expansion of intravascular space

Iso tonic crystalloid 0.9%NaCl = 20ml/kg over 20 minutes
Ringers
Plasmalyte
Reassess after each bolus
Repeat up to 60ml/kg

No improvement ? Reassess for other pathology e.g septic

shock

NB NB check glucose !!!!

 Replacement phase
Existing deficit
%dehydration x body weight x 10 = ml
50% given over first 8 hours, the rest over next 16hrs

+
Maintenance fluids
Calculation :
100ml/kg first 10 kg
50ml/kg next 10kg
25ml/kg for each kg above 20kg

Give fluids as 0.45%NaCl + 5% dextrose

Add 10mmol KCl to each 500 ml
NB . Ongoing losses !!!!!
NB darrows contains K
 Electrolytes
Acidosis
Assess on blood gas
Bicarbonate supplement : 1/3 x base deficit x body weight

Hyponatremia
Treat if Na < 125
Calculate Na deficit = (Desired Na Measured Na) x 0.6 x kg
Safe rate of change = 12mmol/L rise / day
Hypernatremia
pure free water deficit
Calculate [(Na 145) /2]x [4ml/kg] x wt (kg)
Safe rate of change = 12mmol/L decline/day
 Severe Dehydration
Management of severe dehydration
requires IV fluids
Fluid selection and rate should be
dictated by
The type of dehydration
The serum Na
Clinical findings
Aggressive IV NS bolus remains the
mainstay of early intervention in all
subtypes
 Isonatremic Dehydration
Calculate the fluid deficit
Deficit (ccs) = % dehydration x body wt
D5NS is fluid of choice
( deficit the bolus) over the first 8hrs
Add maintenance and any ongoing losses to
above
Further the deficit replaced over the next 16hrs
Monitor electrolytes and U/O
Hypernatremic Dehydration
Fluid deficit =
(Current Na/Desired Na 1) x 0.6 x body wt
Replace with D50.2%NS
Replace over 48hrs
Reduce sodium by no more than 10mEq/L/24hrs
( deficit the bolus) over the first 24hrs
Add maintenance and any ongoing losses to
above
Further the deficit replaced over the next 24hrs
 Hyponatremic dehydration
Na deficit =
(Nadesired- Nacurrent) x 0.6 x Weight (kg)
Divide above by Na in mEq/L within
the replacement fluid
154 mEq in NS
77 mEq in D5 NS
513 in 3% saline
divide by deficit x 2 to determine
rate at 0.5mEq/L/hr
 Hyponatremic Dehydration
If seizing
Correct with 3% Saline bolus
Target a Na of 120
Further correction beyond this with D5 NS
If not Seizing
Correct with D5 NS
Target a Na of 130
Watch for Central Pontine Myelinolysis
More likely in chronic hypo-Na with less Sx
Correct slowly at rate of 0.5mEq/L/hr
 Alternative antimicrobials for treating
cholera in children are TMP-SMX (5
mg/kg TMP + 25 mg/kg SMX, b.i.d.
for 3 days), furazolidone (1.25
mg/kg, q.i.d. for 3 days), and
norfloxacin.
 CAMPYLOBACTER

Erythromycin is hardly used for diarrhea today.

Azithromycin is widely available and has the
convenience of single dosing. For treating most
types of common bacterial infection, the
recommended azithromycin dosage is 250 mg or
500 mg once daily for 35 days. Azithromycin
dosage for children can range (depending on
body weight) from 5 mg to 20 mg per
kilogram of body weight per day, once daily
for 35 days.
Quinolone-resistant Campylobacter is present in
several areas of South-East Asia (e.g., in Thailand)
and azithromycin is then the appropriate treatment
 PROBIOTICS
Several probiotics (Saccharomyces boulardii ,
Lactobacillus rhamnosus and a mixture of
Lactobacillus acidophilus and
Bifidobacterium bifidum) had significant
efficacy (at preventing travelers diarrhea)
Probiotics mixture reduced the severity of
diarrhea and length of hospital stay in children
with acute diarrhea. In addition to restoring
beneficial intestinal flora, probiotics may
enhance host protective immunity such as
down-regulation of pro-inflammatory cytokines
and up-regulation of anti-inflammatory cytokines
 Antimotility Drugs

loperamide is the agent of choice for adults (46

mg/day; 24 mg /day for children > 8 y).
for mild to moderate travelers diarrhea
(without clinical signs of invasive diarrhea).
inhibits intestinal peristalsis and has mild
antisecretory properties.
should be avoided in bloody or suspected
inflammatory diarrhea (febrile patients).
Significant abdominal pain also suggests
inflammatory diarrhea (this is a contraindication
for loperamide use).
loperamide is not recommended for use in
children < 2 y.
 Antisecretory agents

Bismuth subsalicylate can alleviate stool output

in children or symptoms of diarrhea, nausea, and
abdominal pain in travelers diarrhea.
Racecadotril ( acetetorphan) is an enkephalinase
inhibitor (nonopiate) with antisecretory activity,
and is now licensed in many countries in the world
for use in children. It has been found useful in
children with diarrhea, but not in adults with
cholera.
Adsorbents:
Kaolin-pectin, activated charcoal, attapulgite
Inadequate proof of efficacy in acute adult diarrhea
 Anti- emetics

A single dose of oral Ondansetron

(a serotonin antagonist anti-emetic)
in children with G/E and dehydration
reduces vomiting, facilitate oral
rehydration and suitable for the use
in emergency department